Psychiatry is the bestSAM TOPP CT1 IN HOUNSLOW
Tonight
u History taking/MSE/formulation/PACESu Psychotic disorders u Bipolar affective disorder u Anxiety disorders u Personality disorder
History taking u Takes a lot longer than you have in PACESu Think general history but a bit spicier u PC u HPC u PMHu Past psychiatric history - include admissions and if informal or under MHAu DH - think about medication side effects, what has/hasn’t workedu FH u Forensic history - convictions u Childhood and personal history – pregnancy/birth, upbringing, school,
relationshipsu Social history - job, benefits, housing, smoking, drugs, alcohol
History taking
u Be curious u Think about the symptoms /signs you are eliciting and what they
meanu Let the patient do the work u Don’t be scared of silence u Psychosis – patience, rapport, gently probe delusions u Mania – formal, boundaries, may need to interrupt u Depression – patience, kindness u Anxiety – focus on the effects it has on their life
Risk
u To selfu Self-harm/suicide
u Self-neglect – self-care, nutrition, physical health
u Adherence with medication
u To others u From others
u Vulnerability, retaliation
u Property u Absconding
Descriptive psychopathology
u Delusions u Fixed, unshakable beliefs, irrespective of counter-argument, that are
unexpected and not in-keeping with a patient’s cultural background
u Autochthonous delusion u Fully formed idea out of the blue
u Delusional perceptionu I saw the traffic lights turn green and I knew I had to rid London of capitalism
u Mood congruent u Seen in affective psychoses – e.g nihilistic (rotting insides) in depression or
grandiose (Jesus) in mania
u Mood incongruent u Seen in schizophrenia – often horrific beliefs discussed without obvious distress
Specific delusions
u Delusions of control (passivity phenomena)u Emotions (affect), desire to do things (impulse), actions (volition),
experience bodily sensations (somatic)
u Infestation: EKBOM – parasites (may be primary or secondary e.gcocaine)
u Jealousy: sexual partner unfaithful – OTHELLOu Love: (no longer Prince) Harry is in love with me – DE CLERAMBAULTu Misidentification: replaced by exact double – CAPGRAS - or single
person impersonating others – FREGOLIu Communicated: psychotic beliefs get transferred – FOLIE A DEUX
Hallucinations
u An internal percept without a corresponding external objectu Can be any sensory modality u Auditory
u Noises or voices u Voices – ask as much as you can. Command, thought echo, 2nd person,
3rd person, talking about or running commentary
u Visual u More common in eye pathology (e.g Charles Bonnet), epilepsy than
psychosis
u Tactile u Alcohol withdrawal, Ekbom, cocaine
Thoughts
u Thought stream u Speed, quality, quantity u Disordered: flight of ideas, poverty of thought
u Thought content u Substance u Disordered: delusions, obsessions
u Thought formu Snapping off/thought blocku Derailment/Knight’s move (break in association of thoughts)u Fusion – two or more related ideas form one idea
u Thought possession u Thought insertion, withdrawal, broadcasting
MSE
u Appearance and behaviour – age, ethnicity, body habitus, clothing, kempt, cooperative, calm/agitated, psychomotor retardation, abnormal movements (EPSEs)
u Speech – rate, volume, tone, formal thought disorder u Mood – high, low, euthymic u Affect – reactive, labile, flat, blunted u Thoughts – content (delusions, obsessions), possession (interference)u Perceptions – hallucinations, depersonlisation/derealisationu Cognition – TPPu Insight –patient’s ideas/explanation
Capacity
u Can they understand, retain, weigh up pros and cons and communicate decision
u Decision specific u Focus on treatment and setting of treatment
Setting
u GPu Community mental health team u Specialist community team – e.g EIP, CIDSu Crisis and home treatment team u Hospital
u Informal, under section of MHA
Differential diagnosis
Formulation and treatment
u Predisposing u Precipitating u Perpetuating u Bio-psycho-social approach
Schizophrenia and related psychoses
u Psychosis is an umbrella term, schizophrenia is a specific psychotic disorder
u Fundamentally a distortion in thinking and perception
Paranoid schizophrenia F20.0u At least one of the following
u Thought interference – insertion, withdrawal, broadcasting u Delusions of control (passivity); delusional perception
u Auditory hallucinations – 3rd person/running commentary
u Or at least two of the followingu Persistent hallucinations in any modality u Catatonic behaviour
u Breaks in the train of thought – incoherent speech, neologisms u Negative symptoms – paucity of speech, withdrawal, loss of interest, blunting
u Duration of at least one monthu Should not be diagnosed in presence of overt brain disease or during states of
intoxication/withdrawal
Other subtypes
u Hebephrenic schizophrenia
u Disorganised speech and behaviour, flat affect, rapid development of negative symptoms, poor prognosis
u Catatonic schizophrenia
u Prominent psychomotor disturbances between extremes of hyperkinesis and stupor and negativism/posturing
u Simple schizophrenia
u Negative symptoms gradually arise without acute episode (no delusions or hallucinations)
u Residual schizophrenia
u Previous positive symptoms less marked, negative symptoms more prominent
u Post-schizophrenic depression
u Depression in aftermath of illness. Must still have psychotic symptoms but depression dominates. Increased risk of suicide
Disorders related to schizophrenia
Schizoaffective disorder
• Schizophrenic and affective symptoms present simultaneously for at least 2 weeks
• No separate episodes of schizophrenia and affective disorders or drug use
• Treat as for schizophrenia +/-mania/depression
Schizotypal disorder
• Odd beliefs, magical thinking• Ideas of reference • Odd/eccentric behaviour, no close
friends • Suspiciousness/paranoid ideas• No delusions/hallucinations
Differential diagnosis
u Organic causes – e.g infection, inflammation, malignancy u Acute and transient psychotic disorder (time)u Mania/depression with psychotic features – congruent delusionsu Delusional disorder (no other psychotic symptoms present)
Epidemiology
u Lifetime prevalence: 15-19 per 1000 u Male:female equal u Earlier average age of onset for males (23vs 26 years)u 20% reduction in life expectancy (10-15 years)u Suicide most common cause of premature death u Significant comorbidity: metabolic syndrome, substance misuse
Cause
u Genesu Identical twin 46%, one sibling 12-15%
u Environment u Complications in pregnancy/childbirth/neonatal period
u Delayed walking and neurodevelopmental problems
u Severe maternal malnutrition
u Maternal influenza in pregnancy
u Degree of urbanisation at birth
u Use of cannabis, esp during adolescence
Pathophysiology
u Too much dopamine u Not enough glutamine u Too much serotonin u Too much noradrenaline u Not enough GABA
Treatment
u Think bio-psycho-social!u All adults following first episode of psychosis
referred to Early Intervention in Psychosis u Intense, specialist outpatient service for 3 years u Care-coordination u Medical reviews with psychiatrist and treatment
with antipsychotic medicationsu Physical health checks u Psychological intervention – CBTpu Support and education for families – carer’s
assessment, family therapy, psychoeducationu Support with employment/educations u Support with social care – housing/finance issuesu Relapse prevention
Antipsychotics!
u First generation u Chlorpromazine (first ever)u Flupentixol
u Haloperidol u Sulpiride
u Second generation u Amisulrpideu Aripiprazole
u Olanzapineu Quetiapine
u Risperidone u Lurasidoneu Caripirazine
u Clozapine
Antipsychotics
u Weird classification u FGA: more associated with EPSEs, akathisia, raised prolactin, tardive
dyskinesia, prolonged QTcu SGA: more associated with metabolic side effects u Little difference between efficacy EXCEPT clozapine u FGA role in rapid tranquilisation (e.g haloperidol) and depot
preparation (e.g flupentixol) u Right drug for the patient
What if it doesn’t work?
u If after 4-6 weeks of treatment at therapeutic dose there is no response, should change antipsychotic (if FGA, should try a SGA)
u If after a further 4-6 weeks at therapeutic dose there is still no response, CLOZAPINE (if no CI)
Common antipsychotics
u Aripiprazole – D2 partial agonist (weak 5-HT1a partial agonism and 5-HT2A antagonism)u Lovely side effect profile – lack of weight gain/sedation/prolactin/QTc,
available as depot
u BUT, can cause agitation and takes 2 weeks to work orally
Common antipsychotics
u Risperidone – D2, 5-HT2A, alpha1 and H1 antagonistu Available as depot (palliperidone)
u BUT weight gain, EPSEs, prolactin
Common antipsychotics
u Olanzapine – D1, D2, D4, 5-HT2, H1, muscarinic antagonist u Very effective (maybe marginally better than other SGAs), minimal
akathisia/prolactin
u BUT sedation, weight gain, metabolic L
Common antipsychotics
u Quetiapine – D1, D2, %-HT2, alpha1 and H1 antagonist u Limited EPSEs/prolactin
u BUT sedation, weight gain
QTc
u Prolonged QTc à torsades de pointes u Regular ECG monitoring
EPSEs
u Parkinsonismu Days to weeks
u Tremor, bradykinesia
u Reduce dose, consider switch, consider procyclidine (anticholinergic)
EPSEs
u Acute dystoniau Within hours
u Uncontrolled muscle spasm: oculogyric crisis, torticollis
u Procyclidine IM/IV
EPSEs
u Akathisia u Hours to weeks
u Restlessness (risk for suicide)
u Reduce dose, consider switch, consider propranolol, benzo, mirtazapine
EPSEs
u Tardive dyskinesia u Months to years, may be reversible
u Abnormal involuntary movements, e.g lip smacking
u Stop procyclidine if taking, switch antipsychotic (clozapine may be the best)
Neuroleptic malignant syndrome
u Life threateningu Mental state change, fever, rigidity, autonomic dysfunctionu Raised CK on bloodsu Stop antipsychotic, get help quickly - ITU
Clozapine
u Mainly blocks D1 and D4, also anti-cholinergic, histaminergic, serotonergic and adrenergic activities
u Smoking lowers plasma concentrations, caffeine increases
u CI – neutropenia, other blood dyscarasias, myocarditis/pericarditis/cardiomyopathy, severe renal, cardiac or liver disease
Monitoring
u Weekly FBC for first 18 weeks, then fortnightly until 1 year, then monthly indefinitely
u Traffic light system u Green carry on
u Amber – twice weekly monitoring
u Red – STOP clozapine, no other antipsychotics, daily bloods, haematology
Side effects
u Commonu Constipation, dry mouth, blurred vision, sedation, weight gain, nausea,
tachycardia, lower seizure threshold
u Rare but serious u Agranulocytosis, blood clot, myocarditis, pericarditis, cardiomyopathy,
NMS, diabetes, intestinal obstruction, fulminant hepatic necrosis
Case
u 55 year old lady with a past history of depression referred to the crisis team by GP due to concerns about mental state following recent appointment
u Lives alone in council owned propertyu Originally from Pakistan – studied zoology, moved to UK in 20su Worked in Tesco until about 15 years ago u Divorced (abusive partner)u No childrenu Distant cousins near London
Case
u Reluctant to let us inu Flat in squalor - hard to access rooms, flies everywhere, smells v bad, tins
of food everywhere, bags of rubbish, moldu Appeared unkempt u Told me that family was trying to kill her and poison her u She knew this because she saw two black cars pull up outside her house u Thinks she is looking after herself ok and the flat is pretty tidyu Thought consultant was trying to kill her u Did not think unwell in any way u Reports from family responding to unseen stimuli u T2DM, HTN, not taking meds
Differential diagnosis
Differential diagnosis
u Organicu Paranoid schizophrenia
u Delusional beliefs, possible auditory hallucinations, prodrome
u Schizoaffective disorderu Mania with psychotic symptoms u Depression with psychotic symptoms u Schizoid personality
What are the risks?
What are the risks?
u Physical – T2DM, living conditions, malnutrition u Others – family?u From others – retaliation?
Questions
u ‘I saw two black cars pull up outside the house and I knew my family was trying to kill me’ is an example of what?u A. Visual hallucination
u B. Delusional perception
u C. Idea of reference
u D. Grandiose delusion
u E. Thought insertion
Where should she be treated?
Where should she be treated?
u Lacks insight u Does not have capacity to consent to treatment or admission u High risks u Difficult to treat in community – will not let us in and will not take
medication u Section 135, section 2
What medication?
What medication?
u Avoid metabolic side effects u Depot might be useful u Risperidone fits nicely u Consider benzos if agitated
Question
u Following hospital admission, who would be the most appropriate team to refer to?u A. GP
u B. Community mental health team
u C. Early Intervention in Psychosis
u D. Cognitive impairment and dementia service
u E. Forensic services
What are other important management options?
Psycho-social
u CBTpu Family education/therapy u Housing – deep clean, ?supported accommodation u Job - ?fit for work, CV help, benefits support
Question
u Imagine she’s 35….u 16 weeks after starting risperidone, she develops amenorrhoea.
What is the most appropriate first line investigation?u A. Thyroid function tests
u B. Pregnancy test
u C. Ultrasound abdomen
u D. Serum prolactin
u E. MRI head
Bipolar affective disorder
u Two or more episodes where the patient’s mood and activity levels significantly disturbed
u On some occasions, hypomania/mania on others depression u BPAD 1 – mania, BPAD 2 – hypomania
Epidemiology
u Lifetime prevalence 0.3-1.5%u M:F is equal (although type II and rapid cycling more common in
females)u No significant racial differences u Mean age of onset 21 yearsu Significant morbidity – work, relationships u Completed suicide in 10% (usually depression)
Symptoms
u Maniau Persistently elevated mood (irritability)
u Increased energy – overactive, not sleeping
u Pressured speech, flight of ideas
u Needs to last at least one week or less if admitted to hospital
u Grandiose, overfamiliar
u Risky behaviours – money, drugs, alcohol, sex
u Impairs social functioning – dramatic effect on work and relationships
Mania with psychotic symptoms
u Usually mood congruent u E.g grandiose delusions
Hypomania
u Very similar to mania but less severe u Lasts for at least 4 daysu Does not impact on social functioning u Does not result in admission to hospital u Does not feature psychotic symptoms
Aetiology
u Genetic and environmental u Stressful life events may precipitate in vulnerable u Drugs
u Antidepressants
u Steroids
u Cardio- digoxin, diltiazem, propranolol
u TB meds, clarithromycin
u Parkinsons meds – levodopa, amantadine
u GI – ranitidine, metoclopramide
Treating maniau Severe behavioural disturbances – benzos u If taking antidepressant – consider stopping u If taking nothing
u Haloperidol, olanzapine, risperidone, quetiapine, u If ineffective, alternative antipsychotic u If still ineffective at max dose, add lithium u If lithium ineffective or unsuitable, sodium valproate (NOT if childbearing age)
u If already taking lithium, plasma levels to optimize treatment and consider antipsychotic
u If taking sodium valproate/others, increase or add antipsychotic u ECT
Treating severe bipolar depression
u If not taking anythingu Fluoxetine + olanzapine
u Quetiapine monotherapy
u If no response, consider lamotrigine monotherapy
Long term treatment
u Lithium is the most effective in the long termu Aim to switch from acute medications to this 4 weeks after manic
episodeu If ineffective/inappropriate, consider valproate, olanzapine or, if
previously effective, quetiapine
Lithium
u Unknown mechanismu Baseline FBC, UE, LFT, TFT, BMI, Pregnancy testu Levels 5 days after starting and 5 days after change in dose, 12
hours post dose
Side effects
u Polyuria/polydipsia (ADH antagonism)u Weight gainu GI upsetu Cognitive problemsu Hair lossu Tremoru Sedation
Long term
u Renal functionu 1% may develop irreversible ESRD
u Stopping may not slow rate of decline!
u Decision based on efficacy, patient views, MDT
u May need dose reduction as kidneys failing
u Hypothyroidismu Levothyroxine, don’t need to stop lithium
u Teratogenecityu Ebstein’s anomaly , prematurity, floppy baby
u Balance of risk
Toxicity
u Upper limit 1.2mmol/lu >1.5mmol/l most will show signsu >2.0mmol/l life threatening]u Tremor, anorexia, Nausea/vomiting, diarrhoea, lethargy u Severe signs – confusion/delirium, fasciculations, hypertonia,
hypotension, arrythmia, seizuresu Adjust dose, send to hospital, may need dialysis u Prevention – hydration, warn of early signsu Be aware of drug interactions which can increase toxicity - NSAIDs,
antacids, ACEi, ARBs, SSRIs
Sodium valproate
u May be used in acute mania or as prophylaxisu Mechanism not fully known u Side effects – GI upset, tremor, raised LFTsu Rare – irreversible hepatic failure, agranulocytosisu LFTs prior to starting and 6 monthly u Not for use in women of childbearing age unless pregnancy
prevention programme in place u High risk of spina bifida, face and skull malformation,
limb/heart/kidney/sexual organ malformation, developmental delay
Other drugs in bipolar
u Lamotrigine u Mood stabilizer and depression
u Be aware of rash – around 10% develop benign rash, minority develop Stevens Johnson syndrome
u Carbamazepine
Psycho-social intervention
u Individual and family therapiesu Psycho educationu Staying well plansu Relapse indicatorsu Preferences for treatment when unwellu Employment support u Benefits/housing support
Case
u A 35 year old man presents with the belief that he is Jesus after God has spoken to him. He is walking around the ward wearing a toga made from his bedsheet trying to ‘heal’ people. He does not accept that being in a mental health unit is acceptable as this is a ‘genuine religious experience’.
u He works as a pastor in a prison. Used to work as a lawyer and semi professional cricket player
u Sleeping lessu Speech fast, some flight of ideas
Differential
Differential
u Mania with psychotic symptoms u Elevated mood, pressured speech, lack of sleep, irritable, grandiose
delusions, auditory hallucination
u MOOD CONGRUENT delusion
u Schizoaffective disorderu EUPD
Question
u This gentleman has previously successfully been managed in the long term with quetiapine. He has recently weaned this down after a period of being well under guidance from his private psychiatrist. What medication would you start in this instance?u A. lithium
u B. quetiapine
u C. olanzapine
u D. sodium valproate
u E. fluoxetine
Anxiety disorders
Agoraphobia
u Anxiety and panic symptoms where escape difficultu E.g tube, lecture theatre, crowdsu Results in avoidanceu M:F = 1:3u Bimodal distribution – 18-35 yrs and olderu Lifetime prevalence 1.3%u Means fear of the marketplace in Greek!u Citalopram, escitalopram, paroxetineu Behavioural: exposure, relaxationu Cognitive: education re symptoms
Social phobia
u Incapacitating anxiety (not secondary to delusional or obsessive thoughts) restricted to social situations
u E.g having a conversation, meeting new people, public speakingu Blushing, sweating, shaking, dry mouth with excessive fear of
embarrassment, humiliation or people discovering the anxiety u May result in avoidance leading to work, educational and
relationship difficultiesu M:F equalu Peaks at 11-15 yrs but often people do not present until 30su CBT, SSRIs, propranolol
GAD
u >6 months of excessive worry about everyday problemsu Autonomic symptomsu Physical symptoms – chest pain, breathing problemsu Mental state symptoms – depersonalization/derealizationu Tension, tingling u F>Mu 45-59 yrs highest
Panic disorder
u Panic attacks – intense fear, horrible symptoms, develop rapidly, reach peak in 10 mins, resolve in 20-30mins
u May be spontaneous or situational u Panic disorder – recurrent panic attacks (not secondary to
something else)u Worry of another attack makes everything worse u F:M = 2:1u 15-24yrs and 45-54 yrsu Differential –substance misuse, endocrine u SSRIs, CBT
Specific phobias
u Recurring, excessive, unreasonable psychological or autonomic symptoms of anxiety with specific object
u M:F = 1:1u Mean age of onset 15 years u Trypophobiau Alektorophobia u Behavioural therapy – exposure u Cognitive – education, coping skillsu No drugs
Anxiety disorders tips
u Could well come up in PACES!u History
u Get them to talk about it freely
u How does it impact life? – work, relationships, alcohol/drugs
u Brief cognitive intervention re symptoms
u Managementu Bio – SSRIs
u Psycho – CBT, education
u Social – assess wider impact and any help needed
OCD
u Obsessionsu Idea, image or impulse that is recognized by the patient as their own
but is repetitive, intrusive and distressing
u E.g contamination, order or symmetry, safety, doubt
u Compulsionsu Behaviour or action recognised as unnecessary and purposeless, but
cannot resist performing. The drive to do the action is recognised as one’s own but there is a subjective sense of need to perform it
u E.g cleaning, checking, counting, arranging
OCD
u Mean age, 20 yearsu M:F =1:1u 0.5-3% general population u Often comorbidities – e.g depression, substance useu Differential – normal, anankastic PD, schizophrenia
OCD
u CBTu Psychoeducation u Family/carer support u SSRIs (may take 12 weeks for response)u ECT
Question
u A 21 year old lady stops attending medical school lectures after she keeps experiencing palpitations, sweating, tremor and chest pain when sitting in the middle of a row. What is the diagnosis?u A. Agoraphobia
u B. Generalised anxiety disorder
u C. Social phobia
u D. Panic disorder
u E. Emotionally Unstable Personality Disorder
Question
u A 45 year old man feels an overwhelming level of anxiety generally throughout everyday life. What would be the most appropriate medication to start?u A. Aripiprazole
u B. Clonazepam
u C. Escitalopram
u D. Mirtazapine
u E. Duloxetine
Personality disorder
u Enduring, persistent and pervasive disorders of inner experience and behaviour that cause distress and significant impairment in social functioning
Cluster A
u Paranoid – sensitive, suspicious, conspiracy theories, distrust of othersu Schizoid –emotionally cold, detachment, lack of interest in others,
fantasy world
Cluster B
u Dissocial – callous lack of concern for others, irresponsible, irritable, aggressive, unable to maintain relationships, disregard and violation of others’ rights, childhood conduct disorder
u Emotionally unstableu Impulsive type – inability to control anger, unpredictable affect and
behaviour
u Borderline type – unclear identity, intense and unstable relationships, unpredictable affect, impulsivity, threats or acts of self-harm
u Histrionic – self-dramatisation, shallow affect, egocentricity, craving attention and excitement
Cluster C
u Anxious avoidant – timid, insecure, fear of evaluation by others, self-conscious
u Anankastic – doubt, caution, pedantry, rigidity, perfectionism, preoccupation with orderliness and control
u Dependent – clingy, submissive, excess need for care, helpless when not in relationship
EUPD
u V common in psychiatry – 1/3 of all outpatients!u Often create unpleasant feelings within us (counter transference)u Top tips
u Be aware of your own feelings
u Remember the high likelihood of traumatic upbringings
u Don’t reject them further!
Management
u No licensed medicationsu Why are so many on meds?
u Co mordbid psychiatric conditions
u We like to medicate to make ourselves feel better?
u DBTu Interpersonal effectiveness, emotional regulation, distress tolerance,
core mindfulness
u Be aware of risk